Provider Demographics
NPI:1902340813
Name:TUMOLO, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TUMOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4605
Mailing Address - Country:US
Mailing Address - Phone:610-394-1330
Mailing Address - Fax:
Practice Address - Street 1:5030 STATE RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-4605
Practice Address - Country:US
Practice Address - Phone:610-394-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016622363LP2300X
PA2016015030363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty